Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Introduction to Shoulder and elbow Dr Haroon Zaffar (FY1)Bones of the Shoulder Humerus ScapulaeHumerus – proximal end Important points to remember - Greater tuberosity – attachment site for infraspinatus, supraspinatus, teres minor - Lesser tuberosity – attachment site for subscapularis - Humeral head – articulates with glenoid fossa of scapulaHumerus – distal end Important points to remember - Lateral epicondyle – origin point for most extensor mucles in forearm - Medial epicondyle - Capitulum – articulates with radius - Trochlea – articulates with ulnaScapula - posterior Important points to remember - Infraspinatus fossa – origin site for infraspinatus - Supraspinatus fossa – origin site for the supraspinatus - Capitulum – articulates with radius - Trochlea – articulates with ulnaScapula - anterior Important points to remember - Subscapular fossa – origin point for subscapular muscle - Acromion - Coracoid process – Coracobrachialis, pectrolais minor and short head of biceps attach here.Clavicle Important points to remember - S shaped bone - Articulates at Sternoclavicular joint and the acromioclavicular joint - Corococlavicular ligament – consists of trapezoid and conoid ligamentMuscles of the Shoulder – Extrinsic muscles Superficial layer Latissimus dorsi - Origin spinous process of T7-T12. Attaches to intertubercular sulcus of humerus - Extension, adducts, medial rotation of upper limb - Thoracodorsal nerve Trapezius - Origin skull, nuchal ligament, spinous process of C7 – T12. Attach to clavicle, acromion and the scapula spine - Accessory nerveotation during abduction, retraction and depression of scapula,Muscles of the Shoulder – Extrinsic muscles Deep layer Rhomboids (minor and major) - Originates from the spinous processes of T2-T5 vertebrae. Attaches to the medial border of the scapula, - Retraction of scapula - Dorsal scapular nerve Levator scapulae - Originates from the transverse processes of the C1-C4 vertebrae and attaches to the medial border of the scapula. - Elevation of scapula - Dorsal scapular nerveMuscles of the Shoulder – Intrinsic muscles Deltoid muscles - Originates from the lateral third of the clavicle, the acromion and the spine of the scapula. Attach to the deltoid tuberosity on humerus - Anterior – Flexion, Lateral – abduction (>15 degrees) , posterior - extension - Axillary nerve Teres major - Originates from the posterior surface of the inferior angle of the scapula. It attaches to the medial lip of the intertubercular groove of the humerus. - Adducts and extends at the shoulder , medially rotates the arm - Lower scapular nerveMuscles of the Shoulder – Intrinsic muscles Supraspinatus Teres minor - Inserts into greater tuberclefossa - Originates from posterior surface of scapula - First 15 degrees of abduction - Inserts into lesser tubercle - Tested by the drop can test - Lateral rotation - Innervated by suprascapular nerve - Axillary nerve Infraspinatus - Inserts into greater tuberclefossa - Lateral rotation - Innervated by suprascapular nerve Subscapularis - Originates from subscapular fossa - Medial rotationsser tubercle - Innervated by subscapular nerveMuscles of the Upper arm – Biceps (anterior compartment) Biceps Brachii - Long head originates from supraglenoid tubercle - Short head originates from coracoid process - Attaches to radial tuberosity - Arm flexion at elbow and supination of forearm - Innervated by musculocutaneous nerve Coracobrachialis - Originates from coracoid process - Inserts into medial humerus shaft - Flexion of arm at shoulder - Innervated by musculocutaneous nerve Brachialis - Originates from medial and lateral surface of humerus - Inserts into ulnar tuberosity - Flexion at elbow - Innervated by musculocutaneous nerveMuscles of the Upper arm – Triceps (Posterior compartment) Triceps - Long head originates from infraglenoid tubercle - Medial head originates from inferior to radial groove - Lateral head originates from superior to radial groove - Attaches to olecranon of ulna - Arm extension at elbow - Innervated by axillary nerveMuscles of the pectoral region Pectoralis major - Consists of sternal and clavicular head Clavicular head – originates from medial clavicle Sternocostal head – originates from sternum and superior six costal cartilages Both heads attaches to intertubercular sulcus of humerus - Adducts and medial rotation - Innervated by lateral and medial pectoral nerveMuscles of the pectoral region Serratus anterior - Originates from lateral aspect of the ribs 1-8 - Inserts into medial border of scapula - Rotates scapula and also holds scapula against rib cage - Innervated by long thoracic nerve Pectoralis minor rd th - Originates from 3 and 4 rib - Attaches to the coracoid process - Stabilises the scapula - Innvervation by the medial pectoral nerveBones of the the elbow Humerus UlnausRadius – Proximal end Important points to remember - Radial tuberosity – bicep muscle attaches here - Radial head – articulates with capitate of humerusUlna – Proximal end Important points to remember - Trochlear notch – articulates with trochlea of humerus - Olecranon – triceps inserts into olecraconElbow joint Important points to remember - Articulations – proximal radioulnar joint, - Ligaments – RCL and LCL - Bursa - Subcutaneous olecranon bursa – between the olecranon and the overlying connective tissue Brachial Plexus 5 musketeers assassinated 5 mice, 5 rats and 2 unicornsMusculocutaneous nerve (C5, C6, C7) Motor innervation - BBC (biceps, brachialis, and coracobrachialis) Sensory innervation - Lateral cutaneous nerve of forearm – innervates skin of anterolateral aspect of forearmAxillary nerve (C5, C6) Motor innervation - Deltoid and teres minor Sensory innervation - Upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoidBlood Supply Branches - Subclavian artery - Axillary artery - Brachial artery - Radial artery - Ulnar artery - Digital arteriesBlood Supply – Axillary artery First Part Second Part Third Part - Once passed the first rib subclavian Thoracoacromial Subscapular artery Superior thoracic artery Anterior and artery renamed axillary artery Lateral thoracic posterior circumflex artery arteries - Lies deep to the pectoralis minor muscleBlood Supply – Brachial artery - Once distal to teres major then brachial artery - Deep artery called profunda brachii - Travels along with radial nerve in radial grooveBlood Supply – Radial and ulnar arteries - Radial artery – posterolateral aspect of forearm - Ulnar artery – anteromedial aspect of forearmBlood Supply – digital branches - Radial artery – supplies a branch to the thumb, the index finger and to the superficial palmar arch – it then continues as the deep palmar arch. - Ulnar artery – gives rise to the deep palmar branch and continues laterally across the palm as the superficial palmar arch.Question 1 Abdulkarim attended the emergency department after dislocating his shoulder while playing rugby. His shoulder was reduced in the emergency department and then put into a sling. Following this, the emergency department doctor tested for sensation in the ' regimental badge area', which was normal. Which nerve is commonly injured during a dislocation of the shoulder joint, and the one in which the emergency department doctor was testing? A) Radial nerve B) Musculocutaneous nerve C) Median nerve D) Ulnar nerve E) Axillary nerve Answer – E) Axillary nerve Sensory innervation – upper Lateral cutaneous nerve of arm innervates skin over lower deltoid known as regimental badgeQuestion 2 Rian a 55-year-old accountant presents to the GP with a painful right elbow. He points to the medial epicondyle of the humerus. He does not recall any predisposing injury but describes exacerbation of the pain when using the arm, which can extend into the forearm. This has caused him to stop playing golf. He is otherwise well and takes no medications. From the history alone, a particular diagnosis is suspected. Examination supports this supposition. What examination finding is most consistent with the suspected diagnosis? 1) Swelling over olecranon process 2) Worsening symptoms when wrist is extended and pronated 3) Worsening symptoms when wrist is extended and supinated 4) Worsening symptoms when wrist is flexed and pronated 5) Worsening symptoms when elbow is flexed and supinated Answer 4) Worsening symptoms when wrist is flexed and pronated Medial epicondylitis – golfers elbow Flexor muscles originate from medial epicondyle therefore movements of flexor muscles will worsen symptomsQuestion 3 A 41-year-old man presents with left shoulder pain following a rugby injury. An x-ray is taken: What is shown on the x ray ? Answer Acromioclavicular joint injuryQuestion 4 A 27-year-old man attends the emergency department complaining of pain in his right arm. He explains that it came on suddenly while lifting at the gym and that now his arm feels weaker than normal. An ultrasound of the upper arm indicates the presence of a tear in the distal biceps tendon. What movement is most likely to be affected? 1) Internal rotation 2) External rotation 3) Pronation and elbow flexion 4) Supination and elbow flexion 5) Shoulder abduction Answer 4 ) supination and elbow flexion Major function of Biceps Brachii is supination as well as elbow flexionQuestion 5 After a fall at home, a 79-year-old woman with a history of osteoporosis experienced a humeral shaft fracture in the distal third of her humerus due to landing on her outstretched left arm. What manifestation would align with the probable nerve palsy she likely experienced? 1. Wrist drop 2. Waiters tip 3. Tinels sign 4. Shortened and externally rotated arm 5. Loss of sensation over regimental badge Answer 1) Wrist drop Distal humeral fracture at risk of radial nerve injury Radial nerve innervates extensor muscles So therefore injury causes wrist dropQuestion 6 An injury to the spinal accessory nerve will affect which of the following movements? 1) Lateral rotation of the arm 2) Protraction of the scapula 3) Upward rotation of the scapula 4) adduction of the scapula 5) Abduction of arm at glenohumeral joint Answer – 3) Upward rotation of scapula Trapezius muscle Attaches to the lateral clavicle, scapula spine and medial process Elevation and rotation during abduction of arm, retraction and depression of scapulaQuestion 7 A 35-year-old patient presents with pain and swelling in the elbow joint after experiencing a direct blow to the posterior aspect of the elbow. On examination, there is tenderness and swelling over the olecranon process. Which of the following conditions is the most likely diagnosis? a) Cubital tunnel syndrome b) Lateral epicondylitis c) Olecranon bursitis d) Medial epicondylitis e) Radial head fracture Answer: c) Olecranon bursitis - Olecranon bursitis is characterised by inflammation of the bursa located over the olecranon process at the posterior aspect of the elbow joint. - occurs due to trauma, such as a direct blow to the elbow, leading to pain, swelling, and tenderness over the olecranon. - This condition is commonly referred to as "Popeye elbow."Question 7 A 7-year-old boy presents to the GP with arm problems after falling from a tree, during which he caught a branch to save himself. On examination, he has a claw hand with a hyperextended wrist. What nerve roots have been damaged in this patient? Answer: C8, T1 Klumpke injury - Paralysis of intrinsic hand muscles ,FDP and flexor carpi ulnaris - Claw hand - Abducted arm during childbirth